Documentation and providing information

Providing Information:Written documentation

Overview of written documentation

• What is the purpose of the diagnostic report? (record of clinical encounter)

• Who is/are the consumers of the diagnostic report? (RNs, physicians, family, school, insurance)

• What makes an excellent diagnostic report? (Informative, scientific, objective, observations, recommendations; concise but thorough and clear)

• What skills are important for excellent documentation? (knowledge)

Purpose of documentation (Paul & Hasselkus, 2004)

• Support diagnosis and treatment• Support reimbursement• Communicate with other practitioners• Justify clinical decisions• Document communication among involved parties• Protect legal interests of the client, service provider

and facility• Serve as evidence in a court of law• Provide data for quality improvement/research

Format

• Varies by clinical setting–Narrative (UNT-SPHS)–Checklist–Template / computer based

Medical Based Practice

• Speed and efficiency are key• Use of check-lists / templates are the norm• Move toward electronic records• Intuitive electronic records becoming more common• Minimal use of narrative format• Format consistent with requirements of funding

sources (Medicare/Medicaid) and regulatory agencies (Joint Commission on the Accreditation of Healthcare Organizations)

Problem-Oriented Documentation

• Frequently used in medical settings for speed/efficiency

• Emphasis on documenting problems and developing a care plan in response to the problem (document the abnormal)Vs.Documenting overall status

Diagnosis/ Problem-Specific Templates

• Information is specific to the type of evaluation• Examples– Voice evaluation– Fluency evaluation– AAC evaluation– Swallowing evaluation

Education Based

• More uniform documentation format based on laws (94-142, IDEA 04, etc.)

• IEP is the central document used for documenting problems, goal areas, recommendations, etc.

• The IEP is reviewed/updated annually• A complete re-evaluation is required every 3 years

Consumer rights re: documentation

• Both HIPAA and IDEA ‘04 specify consumer’s rights to access and give input re: records

• HIPAA outlines a procedure for a client to request a change to a medical record. The provider is allowed ultimate authority regarding ammendment

• Parents must sign an IEP to express agreement and have due process if necessary

Characteristics of the Evaluation Report

Style• Objective• Third person• Formal, no slang• Precise/specific: clear word selection; avoid nebulous

words such as “good,” “some trouble with” or “problem with” Be objective!

• Concise• Informative• Accurate• Neat and legible

Information• Identifying information• History• Statement of the problem• Evaluation results• Impressions (diagnostic statement, “findings consistent

with…”• Prognosis, for what? E.g., “prognosis for communication

improvement is poor…ALS (expected course of the disorder)• Recommendations (referrals, more test, therapy trajectory,

goals)

Identifying Information• Name• Address• Birthdate / age• Referral• Medical diagnosis• Guardian

History• Presenting complaint/problem• Description/example• Developmental/medical/educational history• Psychosocial information (social expectations, reports

of behavior problems, loner, very outgoing, etc.)• Previous history/treatment• Goals for the evaluation

History should be summarized as concisely as possible

Example• Mr. Smith is a 74-year-old retired plumber who

suffered a left-hemisphere stroke on 6-14-09 resulting in dense left hemiparesis, severe aphasia, and dysphagia. He is currently on a mechanical soft diet with level III thickened liquids. He is inconsistently able to communicate basic needs. His discharge plan is to return home with his wife and continue out-patient therapy.

Evaluation results• Fill name of test, underlined, with abbreviation in

parenthesis - Preschool Language Scale, 4th edition (PLS-4)

• Brief description of the test – “Is a standardized, norm-referenced test use to measure overall language skills in children ages 2 – 5 years

• Results – overall scores/ subtest scores• Interpretation

Example: CELFLanguage Index Skills measured Standard Score

Core Language General language ability

72

Example interpretation• The Core Language Score is a measure of a student’s

overall language ability and is used to make decision about the presence or absence of a language disorder since it is obtained from the subtest that best discriminate typical language performance from disordered language performance. Sarah’s standard score of 72 places her -1.72 standard deviations from the mean, indicating that her performance is most like children with a language disorder.

Example: CELFSubtest Description Raw Score Meets

criterion

Phonological awareness

Measures knowledge of the sound structure of the language and the ability to manipulate sounds

12 No

Example: Interpretation Statement• Phonological awareness is closely linked to reading

and spelling and has been shown as a valid predictor of a child’s ability to learn to read in multiple studies. Joe’s failure to meet criterion indicates that he does not have adquate phonological skills to support reading achivement

Observational assessmentObserved skill Usually present

(80% or more)Occasionally present (50% or less

Not present

Usese visual/written cues

X

Requests repetition from teacher

X

Verifies/ confirms understanding of assignment

X

Example: Interpretation Statement• Results of observation in John’s classroom indicate

that he does not consistently utilize strategies to assist him with comprehension of information in the classroom setting

Example: Dynamic assessmentPhonological Awareness Skills

Pre-intervention accuracy

Post-intervention accuracy

Syllable blending 35% 80%

Rhyme detection

60% 90%

Rhyme production

45% 75%

Initial phoneme identification

20%` 60%

Example: Dynamic assessment interpretation• John demonstrated improvement in all phonological

skills covered during a mediated learning experience where he was provided direct instruction, indicating good potential for rapid development of phonological skills with intervention

Impression

• Provides a clear, concise summary of the diagnosis, functional skills and prognosis

Example of impression

• John presents with a moderately severe specific langauge impairmemtn (SLI) that continues to interfere with academic success. Although John demonstrates good response to speech-language therapy, it is anticipated he will continue to need academic supports and modification for the next 3 years to assure educational success.

The impression section should

• Specify the disorder• Specify severity of the disorder• Document the impact of the disorder on function• Provide a prognostic statement

Recommendations

• Documents comprehensive recommendations and specific recommended action items (not just the need for therapy!!!)

• Should include– Need for additional assessment / referral– Need for therapy– Recommended therapy plan (goals, areas of focus)– Recommend environmental modifications– Recommendations for client/family education

An excellent report• Is accurate• Is clear• Does not contain spelling /grammatical errors• Is easy to read• Includes both data and interpretation• Includes all relevant assessment information (std. tests,

observations, dynamic assessment)• Provides clear impression• Provides specific, comprehensive recommendations

(NOT JUST ENROLL IN THERAPY!!!)

Tips for writers

• Consider the situation• Consider the reader(s)• READ, READ, and RE-READ• Use words that clearly and concisely describe the

behavior/ skill/ condition• Be objective – interpret a behavior only with

evidence “Seemed bored with the activity” vs. “Stated that the activity was boring”

Tips for writers (cont.)

• Be careful about making statements that present the client as not motivated (“Did not want to continue with the activity” vs. “Required consistent encouragement and reinforcement throughout the activity”)

• Avoid jargon• Delete unnecessary words, sentences, and phrases• Use charts, etc. to summarize data, including

informal assessment results

What’s in the future?• Increased use of electronic documentation• Computer assisted documentation / decision-making• Consumer ownership of medical data• More information on efficacy and effectiveness of clinical

practices, especially as electronic documentation increases– Efficacy: Existence of a measurable change in a patient

characteristic as a result of treatment (related to “body structures and functions” and “activity” components in WHO-ICF)

– Effectiveness: Effects of treatment on a patient’s daily life well-being (related to the “participation” and “context” components of WHO-ICF)

Providing Information: Information-giving interview, post-

assessment interview, the exit conference

Clinician Anticipates Some Common Client Complaints

• Quantity of information– Too much– Too little

• Quality of information– Inaccurate– Over-accurate

Information-Giving Interview

• (Pre-interview)• Opening• Body • Closure

Information-Giving Interview

• (Pre-interview)– Prepare room– Compile materials– List key findings

Information-Giving Interview• Opening (pp. 121-124 in SR)

– General orientation statement• Goals• Time• Sufficient info gathered (or not)• Nature of interaction/cooperation

(page 122 of S&R): “Ben was very cooperative and worked hard during the whole session. I was able to get a good sample of his speech and how he’s making his speech sounds. I want to take the next 10 to 15 minutes to share the results with you.”

Information-Giving Interview• Body – Structure: Funnel vs. inverted funnel

• When anxious• When less anxious, or when individual has doubts about the

presence of a communication disorder

– Content• Three to five major points (save rest for later)• Two-way street: See if they have questions• Realistic picture: Positive and negative

– Direct, honest, compassionate– Sandwich them (don’t chunk them)

»Why? What would happen if you did chunk them?

Information-Giving Interview

• Closure – Complete 2-way discussion• Summarize

– Findings– Conclusions– Suggestions recommendations

• Ask for questions– May allow for “processing time”

– Thanks– Next steps (future): Offer constructive action

Information-Giving Interview: Body(continued, suggestions)

• What if there are more than 3-5 points?• Keep language simple

– No jargon, or if you have to use them, define them– No test or protocol names

• Watch for signs of misunderstanding, overload, or resistance• Handling emotional responses

professional, supportive, matter-of-factexpress sympathy when appropriate (“must be difficult time for

you” “I’m so sorry” “I’ll do whatever I can to support you”)Q: Why would you NOT say “I know how you feel” “I

understand what you are going through”

Approaches in Information-Giving

• Treat all members as “conversational equals”• Offer constructive action• You may be seen as “bearer of bad news”• Provide encouragement when possible and

appropriate• Don’t expect immediate action on suggestions